Social Anxiety and Its Treatment

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Social Anxiety and Its Treatment

• David M Clark
• Institute of Psychiatry, Kings College London

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Anxiety and Anxiety Disorders

• Anxiety is a survival mechanism
• Motivator and sometimes life saver with real
  dangers
• Problematic when danger is imagined
• Anxiety Disorder diagnosed when anxiety is out of
  proportion to the danger, is persistent, and
  disabling. One year prevalence 17
• Cost 42 billion per year (US, 1990s).

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Social Phobia(Social Anxiety Disorder)

• Most common anxiety disorder (12 prevalence)
• Persistent fear of social or performance
  situations. Individual fears he/she will act in
  a way which will be humiliating or embarrassing.
• Fear recognised as excessive or unreasonable
• Feared situations are avoided or endured with
  intense distress

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Characteristics and Consequences

• Typically childhood onset (median 13 yrs).
• Low natural recovery rate (Bruce et al 2005 37
  over 12 years).
• Increased risk of suicide, alcohol drug abuse,
  depression, other anxiety disorders.
• Marked under-achievement
• Low treatment seeking rates

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Typical Thoughts

• What I say sounds stupid
• Im boring
• I will make a fool of myself
• They dont like me
• Theyll see Im anxious
• I wont have anything to say
• Ill blush/shake/lose control

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Existing Treatments

• Medication
• MAOI (phenelzine)
• SSRIs (paroxetine, sertraline, fluvoxamine,
  fluoxetine)
• (effective in short-term but problematic relapse
  )
• Psychological
• Exposure therapy
• Group cognitive-behavior therapy
• (effective in short-term gains well-maintained
  )
• BUT less than 50 recover.

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Clark Wells (1995)

• SOCIAL PHOBIA PERSISTS DUE TO
• shift to internal focus of attention
• use of internal information to infer how one
  appears to others
• safety behaviors

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Social Situation
Activates assumptions
Perceived social danger
Processing of Self as a Social Object
Safety Behaviours
Somatic cognitive symptoms
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Mansell, Clark Ehlers (2003)

• Do high socially anxious individuals have an
  internal attentional bias?
• High vs Low Socially Anxious Students
• Detect external and internal probes
• Threat vs No Threat

Source Behaviour Research Therapy, 41, 555-572.
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External vs Internal Focus of Attention
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Hackmann, Surawy Clark (1998)

• Do patients with social phobia experience
  negative, observer perspective images when
  anxious in social situations?
• Structured interview.
• Frequency, content perspective of spontaneous
  imagery

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Negative, distorted, observer perspective images
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Link between date of memory and onset of social
phobia
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Wells, Clark, Salkovskis et al (1995)

• Do safety behaviours prevent cognitive change?
• Exposure with safety behaviours
• VS
• Exposure without safety behaviours

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Improvement
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New Cognitive Treatment

• Derive idiosyncratic version of model
• Self-focussed attention/safety behaviours
  experiment
• Video feedback
• Shift attention to social situation
• Behavioural Experiments
• Construct veridical image of social self

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• Ill sound stupid
• Self-Conscious
• Image of self
• looking very strange
• twisted mouth and rigid
• feel different and apart
• Safety Behaviours Anxious
• Delay asking, take deep breaths
  uncomfortable,
• Speak quickly, mumble, hand over
  sweaty palms,
• mouth, rehearse what about stiff
  muscles,
• to say, check memory for what mind goes
  blank,
• I have just said

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New Cognitive Treatment

• Derive idiosyncratic model
• Self-focussed attention/safety behaviours
  experiment
• Video feedback
• Shift attention to social situation
• Behavioural Experiments
• Construct veridical image of social self

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Attention and Safety Behaviours Experiment

• Difficult social interaction (twice)
• Focus on self safety behaviours
• versus
• Focus externally no safety behaviours
• Compare subjective anxiety, catastrophes,
  performance

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Video and Audio Feedback

• shows true observable self
• but can continue to process internal information
  or discount accuracy of image
• therefore run mental video first and
  operationalise conspicuousness of negative
  behaviours
• can help patient drop safety behaviours by
  showing they are more observable than feared
  symptoms

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New Cognitive Treatment

• Derive idiosyncratic model
• Self-focussed attention/safety behaviors
  experiment
• Video feedback
• Shift attention to social situation
• Behavioral Experiments
• Construct veridical image of social self

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• Interrogating the Social Environment
• Behave in unacceptable fashion and observe
  others response (WIDEN BANDWIDTH)
• - pause in speech, umms and ahs
• - damp armpits
• - shake/spill drink
• - wear blusher
• - disagree/express opinion
• - ignore acquaintance
• 2. Conduct surveys
• 3. Articulate and discount imaginary critic

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Social Phobia Trial 1(Clark, Ehlers et al, J.
Consult. Clin. Psychol. 2003, 71, 1058-1067)
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Social Phobia Trial 2 (Clark, Ehlers et al. in
press)
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Trial 3 (Mortberg, Clark et al. in
press)Stockholm